[ashbyboulware]

#9527

Dr Corenman, I am a 38 year old male. In october of 2012 my left arm went numb unexpectedly after weeks of neck pain,shoulder and arm pain, and upper shoulder spasms. I was also experiencing intermittent chest wall pain. After a doctor consult, a nuclear stress test and mri were ordered. Stress test was normal, Mri came back with this radiologic report.Their are slight central disc bulges at c4-5, c5-6,c6-7, without significant spinal stenosis. Their is mild neural foraminal narrowing bilaterally at c5-c6. The right unconvertebral hypertrophy at c4-c5 results in mild right neural frontal narrowing. Their is slight frontal narrowing on the front at c3-c4. The cervical spinal cord demonstrates appropriate signal intensity. No epidural collections are identified. After discussings with my doctor i opted for conservation and was managing fine with Meloxicam and Robaxin. In January 2013 things changed. I was en route to work when a driver ran a red light on a busy highway. A vehicle swerved to avoid hitting the vehicle and struck my vehicle, causing it to hydroplane. I lost control and crossed the highway divider, entering a pile of cars. All vehicles were moving approximately 50-60 mph, as was I. When i hit the divider my vehicle bounced and turned sideways and fortunately I was struck on the passenger side(very violently). The crash resulted in horrible whiplash, and i was taken to the e.r. for a ct scan. The e.r was very busy that morning, and since my neck wasnt broken they sent me home with flexoril and advil and a “contact your primary” letter. about 3 days post wreck in addition all the whiplash and ddd symptoms in my neck arm chest fingers etc, I began to feel a vertical line interscapularlly/medial border on the left side of my body that felt like an electrical transmission line running down it.I saw my doctor immediately and notified him of the new symptom. He decided that their was so much inflammation in my body from whiplash, that it could possibly go away after the inflammation died down. Well, the interscapular pain continued to progress. The pain in the left scapula radiated, throbbed, burned. Muscles spasmed all day to the point that it would lock that area up. My other radiculopathy symptoms became more pronounced.Essentially my condition was deteriorating. Based on the location of where i told my primary i hurt(left interscapular, medial border), he wanted to order a thoracic mri. I asked and felt that with my known ddd, and based on the new symptom,I felt that with the whiplash trauma to my neck that a cervical was more prudent than thoracic, as obviously the thoracic spine is more reinforced. I asked could we not do both since i would be on the mri table? He explained that insurance would only pay for 1 body part at a time and, “we already know your neck is messed up anyway”. So I as the patient, agreed to the thoracic, which pretty much came back uneventful with the exception of 2 notations…i am summarizing..minimal loss of height involving the upper endplate of t8 vertebrae with no evidence of bone marrow edema(mri performed 3/26/13, wreck 1/15/2013). Some minimal degenerative disc changes noted, including a small central protrusion at t7-8, and t9-10. I chalked this up as not part of my pain. At this point I felt that my problem was out of the scope of my primary and asked for a competent referral to a specialist which he gladly obliged. The specialist was a neuro-surgeon who also specialized in musculoskeletal disorders. His pedigree seemed to make him well qualified. On the date of my appointment we met. I gave him all the backstory going back to oct 2012 with a disc containing the mri from nov 2012, thoracic mri, ct scan from er along with radiology reports. He concurred with me that another cervical mri was in order. he ordered it. However, no flexion, extension, static xrays of any kind were taken. He never palpated anything and I dont remember doing any range of motion tests. After the mri was done I was scheduled for a follow up in approx 1 week from date of mri. At this point it was April 2013, and I was in chronic daily pain. The scapular pain was unwielding. To make matters worse, I am a telecom technician which requires me to carry heavy equipment, and to place my body in positions kinetically that caused extreme pain. I went and picked up the mri report 3 days before my follow up, so sure that based on how badly i felt, the problem would be in BOLD, Blatantly obvious what was causing it. To my dismay, the mri report done by a farmed out radiologist essentially used radiologic terms to say that they used the nov 2012 for a comparison, and that their was no noteable changes..nothing. I was devastated. I consulted a friend who was a pt that day, and he told me he knew the doctor, and that in his opinion, if I wasnt an immediate candidate for surgery he would punt me. I made plans to use him for P.T. if that is the route the doctor wanted to go to get me out of his office. When I got home my wife knew I was a wreck. my back was essentially locked up in the scapular area from spasms. She laid me down to give me a massage and once i was on my stomach, it became very obvious that their was a huge pocket of edema all around the left scapula. She took numerous pictures so I could give my doctor more documentation that something was wrong. On my follow up, he discussed the mri, and basically punted me. He didnt really want to look at the pictures. He essentially offered nothing. he mentioned pt and asked if I had done any. I told him i had no problem with pt, but could he please tell me what was causing me my pain so that i could tell the therapist what i needed therapy on. He glossed that over and jumped at the chance to send me packing when i mentioned my pt friend. I was in such god awful pain, I asked him if he felt pain management was prudent as my quality of life was almost nonexistent. As an afterthought he said he would have his psyiatrist call me for an appointment to possibly try some blocks. the psyiatrist called to schedule and upon hearing my injury was from an auto wreck and that I had retained counsel, they did not want my business. I informed them that my lawyer was to negotiate between me and my insurer, as the cause of the wreck was essentially a hit and run. they didnt care. I was dismayed. For a reference the second cervical mri was on 4/9/2013, almost 3 months from the wreck. I started pt and went through 8 sessions. No help. PT referred me to psyiatrist who performed a multi level cervical epidural down to somewhere in the thoracic area. Absolutely no relief. The only time I ever got any relief from the daily pain was from hydrocodone prescribed by my primary and when i laid down flat on my back. Hydrocodone made it somewhat tolerable, taking a lttle of the edge off. laying down and i didnt hurt. At this point I began to panic as I was amassing lots of missed time from work, spending lots of time and money at various doctors, and felt no closer to resolution. I kept insisting that based on the scapular pain arising 2-3 days post wreck, something had changed. It also appeared muscles in my back,shoulder, and upper arm were wasting. Long story short, I was evaluated by another doctor, an ortho approx a week after my block. He took x-rays first. Took a history, symptoms etc. examined me and then read the radiologic reports. He noted that my facet joint at c5-c6 looked “odd” from the x rays.That it looked like it had sustained a small avulsion fracture. He then said, let me go look at the mri. he returned 2 mins later and point blank told me that I had a herniation at c5-c6 with spinal stenosis. I asked him, “how does this get missed by all these professionals”? His reply was he wasnt really sure how…its right there..He then discussed possible acdf if diagnosis was correct. He then sent me for a snrb at c5-c6.he stated as you have, that if i even got a coupla hours or relief from the numbing agent that they were on top of it. The only flaw with this plan is that you are told to rest and take it easy. Which I did. And if I rest and lay down i dont hurt regardless. I
will say that i was pain free for at least a coupla hours. But thats about it. On my follow up with him, I told him that I had some relief from the snrb. He then decided the best course of action was to wait, and that hopefully the herniation would dry out and be absorbed. This was mid July. As a sidenote, they also did a nerve conduction test to rule out plexopathy from radiculopathy. the brachial plexus was ruled out. Although very happy that somebody had finally acknowledged that something had happened from the wreck and validated my suspicions, I physically continued to degress. I started losing motor function in my left arm. Bicep was burning all the time and fatigued. My thumb and pointer fingered hammered on me all day. Cool damp weather wreaked havoc on me. Hypersensitive to cold or heat. But the absolute worst has been the Scapular pain which has never deviated in giving me a daily thrashing. I finally conferred with my pt, who referred me to a very respectable neurosurgeon. I arrived early and had more xrays taken. The neurosurgeon ran the gamut of range of motion tests and reflex tests. Looked at my MRI, and once again confirmed that the herniation was there and that my symptoms were textbook c5-c6 compression with disc disease. I was pre-admitted that day for acdf c5-c6, and 3 weeks later on sept 11th(8 months after wreck, and 11 months from first presentation of neurologic deficits) I had the acdf procedure. The surgery was flawless. I am approx 23 days from surgery and my fusion seems to be healing very quickly. Titanium plate with spacers and bone shavings were used. I ate a whole meal 3 hours after surgery. Solid food. Stayed overnight and released the next day. was very sedentary in the hospital, and the first day or so as I was home. However walking around was no trouble even the day of surgery. I wore no collars of any kind and have at this point minimal stiffness and good range of motion. Unfortunately, my symptoms have never really diminished. Felt better the first coupla days, but i chalk that up to laying down most of the time. As i began to slowly get back in the groove, all my symptoms have come roaring back with the exception of the pins and needles in my arm. Hand and arm are still very hypersensitive. As more time passes my bicep pain and weakness has returned and the coup de grace..the scapular pain is still wreaking havoc on me. So, All that being said, I have a handful of questions. Do you agree with the diagnosis of c5-c6 being the problem? For the record, I had myelopathy associated with the herniation, so the surgery I feel was necessary, regardless. Did too much time go by before surgical intervention to hope for a recovery of the nerve root. The surgeon said he had to remove numerous osteophytes that were part of the nerve compression problem in addition to the herniation. Is it too early to evaluate nerve root damage? I need to know sooner rather than later if its another level causing me problems scapularly due to limited disability off work, and the clock ticking on compression if its elsewhere? should I ask for a nerve conduction test for the muscles around the scapula innervated by c6? Part of my struggle with the pain that has remained is the not knowing for sure that the right nerve was addressed for my primary complaint or is it chronic radiculopatyhy? And lastly, how does a radiologist fail to note a herniation that is causing nerve root compression and spinal stenosis, and did I not have enough neurologic “deficits” for the first neuro to realize the urgency of my case. What is his standard professionally? And could you comment on the possibility of non repairable nerve root damage in my case based on duration and symptoms. Where did I go wrong? Thanks Dr C, I have learned alot on this forum.

[Donald Corenman, MD, DC]

#9531

Well-unfortunately you have seen a side of medicine that is somewhat difficult. Sometimes care is not what you would expect with all the egos running around.

I am unclear as to what is currently happening with you. You had what you report is a missed C5-6 foraminal and central stenosis disorder. Your symptoms did sound like a radiculopathy of the C6 nerve (pain in biceps, numbness in thumb side of hand and medial scapular pain) but you described no myelopathic symptoms (incoordination, fine motor skill loss, balance problems, Lhermitte’s sign-see website, bowel/bladder dysfunction, etc..).

The SNRB you underwent sounds to be partially diagnostic in that you had normal pain going into the injection and had initial relief. Unfortunately, you did not test the relief by reproducing activities in the first three hours that typically cause pain. Nonetheless, this sounds diagnostic.

The symptoms being relieved but then returning to the same level as prior to surgery makes me thin of two potential disorders. One is a pseudoarthrosis of the fusion site (lack of fusion) which can cause recurrent nerve compression. Normally, the symptoms will dissipate for two to three months and then return in a case like this.

The burning and hypersensitivity symptoms make me concerned. These two symptoms are generally not related to nerve compression but to nerve injury-something called neuropathic pain (see website under chronic radiculopathy or peripheral neuropathy).

Nerve conduction tests can be helpful in certain cases but in your case, I am unclear as to the value to these tests. You should start with a request to your doctors for imaging tests to assess the current “state of affairs”. In my office, a patient with your symptoms would have a thorough history and physical examination, CT scan, MRI and X-rays with flexion/extension to start off.

Dr. Corenman

PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
 
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.

[ashbyboulware]

#9532

My apologies Dr Corenman for an incomplete history, As i have had to be my own advocate and continue to push for answers to what is quite obviously neuropathy/radiculopathy…some variant of nerve generated pain, i would say I have had to, “learn on the job” as I have never really gotten much info from doctors on my condition/conditions. When I was diagnosed with ddd with radiculopathy in october 2012, I was told their was 3 options to treat. pt, conservative medicine, and surgery. I was never given nor told of the consequences of progressive nerve compression, nor the symptoms of progression and what to watch for. I was not aware of the consequences of failing to decompress a compressed nerve. Most of my ddd was sensory up until the acute trauma from whiplash in January 2013. My myelopathic symptoms were transient weakness in legs and arms, transient shocks or discharges felt randomly in my body(whole or part), trouble at times with fine motor skills i.e. buttoning small buttons on a shirt, nausea and mild vertigo..lots of nausea(or pain induced nausea)?, and frequency/urgency of urination. I appreciate your insight. I believe that your assessment of chronic neuropathy or radiculopathy is accurate. my fear is that as an uninformed layperson, I was at the mercy of doctors who relied on radiologist, who missed the herniation, and my clock was ticking. I knew something was being missed. As a technician I tend to look at things through a troubleshooting aspect. Symptoms were static until a traumatic event…then new presentation of a new symptom means something had occurred from the auto accident. Even I can see the herniation on the mri post auto accident. my herniation was extending into the spinal canal and was touching or was very close to touching the spinal cord. Its almost as if he never looked at it. Would a ct myelogram be prudent at this time? Any specifics with the mri variables that you would recommend that might reveal something unseen on an mri w/o contrast? I know that the c5-c6 herniation with myelopathy was an accurate diagnosis, and the acdf an appropriate repair. I just need closure on whether the “pain generator” is a permanently damaged nerve root at c6, or pain from another level. Any additional advice would be appreciated. What is the best way to approach the neurosurgeon without putting him on the defensive, as I am not questioning the c5-c6 diagnosis, nor the acdf. Im simply needing to put my fears to rest of an additional nerve problem. Thanks again.

[ashbyboulware]

#9544

My apologies Dr Corenman for an incomplete history, As i have had to be my own advocate and continue to push for answers to what is quite obviously neuropathy/radiculopathy…some variant of nerve generated pain, i would say I have had to, “learn on the job” as I have never really gotten much info from doctors on my condition/conditions. When I was diagnosed with ddd with radiculopathy in october 2012, I was told their was 3 options to treat. pt, conservative medicine, and surgery. I was never given nor told of the consequences of progressive nerve compression, nor the symptoms of progression and what to watch for. I was not aware of the consequences of failing to decompress a compressed nerve. Most of my ddd was sensory up until the acute trauma from whiplash in January 2013. My myelopathic symptoms were transient weakness in legs and arms, transient shocks or discharges felt randomly in my body(whole or part),tinnitus, trouble at times with fine motor skills i.e. buttoning small buttons on a shirt, nausea and mild vertigo..lots of nausea(or pain induced nausea)?, and frequency/urgency of urination. I appreciate your insight. I believe that your assessment of chronic neuropathy or radiculopathy is accurate. my fear is that as an uninformed layperson, I was at the mercy of doctors who relied on radiologist, who missed the herniation, and my clock was ticking. I knew something was being missed. As a technician I tend to look at things through a troubleshooting aspect. Symptoms were static until a traumatic event…then new presentation of a new symptom means something had occurred from the auto accident. Even I can see the herniation on the mri post auto accident. my herniation was extending into the spinal canal and was touching or was very close to touching the spinal cord. Its almost as if the radiologist never looked at it. Would a ct myelogram be prudent at this time? Any specifics with the mri variables that you would recommend that might reveal something unseen on an mri w/o contrast? I know that the c5-c6 herniation with myelopathy was an accurate diagnosis, and the acdf an appropriate repair. I just need closure on whether the “pain generator” is a permanently damaged nerve root at c6, or pain from another level. Any additional advice would be appreciated. What is the best way to approach the neurosurgeon without putting him on the defensive, as I am not questioning the c5-c6 diagnosis, nor the acdf. Im simply needing to put my fears to rest of an additional nerve problem. Dr Corenman, I would like to add additional symptoms in conjunction with my neuropathy.I am now roughly 26 days post op. Throughout this ordeal, and as of yesterday, my scapular pain was as bad if not worse than they have been since this started in January. When the scapula gets to the point of unbearable, it is usually accompanied by large amounts of “edema” surrounding and over the scapula itself. I also have edema in pockets on the right side of my spine in certain places. Also, the pain and edema is accompanied by significant amounts of “trigger points” on both sides of my back, icluding two large ones yesterday amongst the others in roughly the same spot of the ribcage area.My wife spent over an hour trying to massage out the trigger points. Whenever she would find one and press on it to get the trigger point to release, i could feel deep pain and pressure referred along the dermatome, with the most substantial response felt in my thumb, trigger finger, the webbing in between, outer pinkie side of hand, and bicep and forearm. This response was felt in my left arm/hand regardless of what side of the back the trigger points were. Does any of this raise a “red flag” of an undiagnosed problem that mimics c6 chronic radiculopathy, or do these signs and symptoms re-inforce chronic c6 radiculopathy? I havent been able to find much in regards to researching the edema. Thanks so much for any insight

[Donald Corenman, MD, DC]

#9556

It is highly unlikely that you are in any significant danger right now after the ACDF. Why you have continuing pain is something that needs a workup. A CT at this point is not indicated but possibly a new MRI might be. Chronic radiculopathy is a diagnosis of exclusion. If there is no evidence of further compression and symptoms are consistent with a nerve injury (pain, paresthesias and numbness), the diagnosis is most likely chronic radiculopathy. A confirmatory test is a selective nerve root block. Numbing the root with 2-3 hours of relief in the case of an MRI without nerve compression generally confirms this diagnosis.

Dr. Corenman

PLEASE REMEMBER, THIS FORUM IS MEANT TO PROVIDE GENERAL INFORMATION ON SPINE ANATOMY, CONDITIONS AND TREATMENTS. TO GET AN ACCURATE DIAGNOSIS, YOU MUST VISIT A QUALIFIED PROFESSIONAL IN PERSON.
 
Donald Corenman, MD, DC is a highly-regarded spine surgeon, considered an expert in the area of neck and back pain. Trained as both a Medical Doctor and Doctor of Chiropractic, Dr. Corenman earned academic appointments as Clinical Assistant Professor and Assistant Professor of Orthopaedic Surgery at the University of Colorado Health Sciences Center, and his research on spine surgery and rehabilitation has resulted in the publication of multiple peer-reviewed articles and two books.

[ashbyboulware]

#9557

Dr Corenman, thanks for your responses. Afyer your initial response, you validated my opinion that their was a nerve damage issue. I went back to the drawing board and poured over the mri. It Now appears that their is a stretch injury at the c5 nerve root with demyelination and partial avulsion. I guess its Brachial Plexopathy all along. I’m not sure if any medical advances have been made that can address that. If its permanency, I’m ok with that. Just wanted finality on the “pain generator”. I’m not asking for a comment on my radiologist, but in general, is it acceptable for a radiologist failing to note a herniation at c5-c6 with cord compression, and a partial nerve root avulsion at c4-c5? How does this happen?

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